This blog is a forum to discuss the opportunities and challenges of cross border health system collaboration in border regions
There are numerous instances where patients may need or seek health care in another member state or where health care might cross the border to meet patients in the form of professionals, e-health. In border regions health care might improve when co operations are set up in a cross border setting. The realization of such cooperation might prove challenging but they can lead to new opportunities. Border regions are special because they can be considered practice laboratories for European integration and collaboration. Health work forces, service delivery, information systems provide ample frameworks for cross border regions to share ideas and master challenges that might result from collaborating European health systems.
Due to the complex adaptive nature of the health systems the effective cooperation of health systems and service provision in the border regions will depend on closing information gaps, identifying good practices, developing tools for the planning and realization of programs, capacity building, mutual collaboration and learning. There are numerous opportunities to share and collaborate in order to ensure better quality of care for the patient by investing more effectively and strategically across the border.
Legal challenges in cross-border health care
In June 2010 the Council agreed on a new proposal Directive for patients' rights in cross-border healthcare. The agreement came after a Council meeting in which a compromise proposal of the Spanish presidency (9948/10 +9948/10 COR 1) was presented. This Directive has a long history, one of the topics of discussion being liability rights. These rights have a close relation to health related cross-border activities in border regions (e.g. emergency and hospital services). In this discussion in both the border regions and on a Directive (EU) level it was claimed that legal challenges hindered cross-border cooperation. On the other hand arguments were put forward that these challenges were overcome by practical solutions and by bilateral agreements; or even that experiences in these border regions could be used to inform EU policy making. The new proposal by Spain will probably lead to a further discussion about what is thought to be necessary for border regions and cross-border health care in relation to liability and other legal challenges.
As is proven regions learn from each other by exchanging experiences; but in what way are regions and the EU pushing each other and which solutions are useful to make cross-border cooperation more adjusted to the (legal) challenges it‘s faced with? These questions can be linked to experiences from border regions, where many different cooperation forms exist that provide the citizens with health care services.
Over the years Europe has provided border regions with the legal capacity to initiate cross-border projects. Legal capacity or not this does not mean that within border regions there is a will or the financial capacity to start cooperation. Regions choose from the wide spectrum of possibilities for cross-border cooperation to suit their local needs. Sometimes this entails more practical solutions, other times cooperation’s choose for a suitable legal framework (e.g. bilateral agreement or legal entity based on EGTC).
Going back to the Directive, over the past years the demand for more legal clarity and solutions for legal challenges was heard clearly. This raised the question of what the exact challenges are that regions and local authorities are faced with. Even though legally there are a lot of possibilities for setting up a cross-border cooperation local authorities still find themselves faced with ‘complex legal structures’ and this leaves them to come up with other solutions for their local demands.
Statement: Do you think that the border regions use legal challenges as an excuse in order not to cooperate or agree on certain pertaining issues – e.g. liability? Your comments and/or experiences are welcome on our blog.
Kommentare
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Wherever is's possible the Euregio Rhine-Waal will not be held back by legal regulations. Therefore we do much bottum-up cross-border projects. (agreements between NL/D hospitals)
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This Directive is very much welcome, as it is a long story behind to get approved. It is not the best text for European border regions, but it is strong step to re-introduce this debate in the European agenda. On the other hand, in this text "cross-border health" is mainly meant to be health care provided to citizens travelling or living in another country, without taking into account "border citizens", those living in border areas (normally peripheral, worst communicated and low populated) without the same access to health services than those living in more "central" areas.
And, regarding the question posed by the blog administrator, I think that border regions would try any kind of cooperation in this sector (this has happened for many years, even in an informal basis), but there are many difficulties due to the assymetries of health systems and services provided, and also due to the many actors involved on both sides of the border: public and private providers, insurance agencies, public authorities, etc. Differences in treatments, patient management, language, etc., are another set of added difficulties.
We will pay careful attention to the opinions included in this blog and hope the debate will be lively and useful for all users.
Association of European Border Regions -
During the predecessor project "Evaluation of Border Regions in the European Union" (EUREGIO) legal problems were often mentioned as an obstacle to cross-border health care provision. Even if regulations at European level would provide solutions to problems in cross-border cooperation, some areas will still suffer from legal uncertainty and require regulations. I assume that most of the border regions would not use legal challenges as an excuse not to cooperate on certain issues. The examples in the Final Project Report (p.58) show that there is a great need for more clarity and legal certainty in the border regions.The amount of cross-border health-related projects indicate that many involved stakeholders are not put off by any legal challenges.
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I fully agree with Gudula Ward that most border regions are not using this legal challenges as an excuse not to cooperate.
But of which "legal challenges" are we talking? The truth is that "legal uncertainty" raised in the debate refered to the conflict between the regulation 1408/71 (now 883/2004) and the jurisprudence. This should be solved if an agreement is reached between Member States and the European Parliament. But no one is able to know how the European Court of Justice will further develop is jurisprudence.
One thing is sure, this proposed directive is mostly about facilitating competition, in particular in border regions. Will it help cooperation? -
Maybe the key to answering the question of legal challenges is not coming from Europe but from the border regions themselves. They do - as is mentioned - work on many different projects and go further even though legal clarity is not always available. But what legal challenges are we still facing and are these connected to legal discourse on a European level?
Border regions need a different legal framework in order to operate across borders this is often forgotten in the creation of regulations; on the other side stakeholders also develop strategies that provide a framework for their specific needs and the border region. In this development sometimes stakeholders might not be aware of the possibilities or the regulations on a European level, thus leaving many legal questions unanswered. Therefore challenges might have to be interpreted as a lack of adaptation to these specific needs of border regions. -
I don't know enough about the topic or the region but this sounds like an interesting question. I am wondering how vast the divide is, in theory and in practice, between legal provisions in European border regions? What are, concretely, the factors that could contribute to legal challenges in regions that, presumably, share similar social, economic and political environments? How do their national and legal policy frameworks differ in tangible ways that would affect health cooperation? Is this really a question of patient rights or is it a question of national health systems wanting to maintain autonomy?
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The (lack of) adaptation to specific needs (legal needs) in border regions surely comes from a difference between what is demanded and what is possible on a national basis.
The divide develops because regions need practical solutions in order to work across borders, but national rules do not always allow for this (or are difficult to translate into what can be done with them in practice).
This does not prevent cross-border health care projects from being set up because on either side of the border people recognize certain similarities in the social/economic/political and health landscape including challenges and opportunities and they therefore try to find solutions that might work for them.
Again this does not mean that their (national) legal frameworks for health care are similar.
Health cooperation is therefore affected not by the wish/possibility to work together across the border but by the legal uncertainties that this may have. Cooperation focuses mainly on what is practical for a specific region and this then leads to legal challenges not being solved in the cooperation. For example when it comes to health care services being offered on the other side of the border a project will look into solving problems that connect to e.g. reimbursement differences between national countries; it does not try to create a new legal framework for that region in which the project (the health care service) is being carried out.
Unfortunately because of these practical solutions in border regions, legal challenges either lag behind or the project (cross-border) will not be initiated at all, since the legal problems seem too vast to overcome.
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Disclaimer: The views expressed in this forum are not representative of the project or the Department of International Health, Maastricht University
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